Questions&Answers: Meniere's Disease Presentation

ENT
Questions&Answers
Q-1
A 28 year old woman complains of recurrent attacks of vertigo and nausea that
last around 30 minutes to a few hours. They occur several times a year. Between
attacks she is asymptomatic. She also reports a mild hearing loss in the left ear.
What is the SINGLE most appropriate treatment?
A. Aspirin
B. Metoclopramide
C. Cyclizine
D. Clotrimazole
E. Ondansetron
ANSWER:
Cyclizine
EXPLANATION:
There are a number of medications that can be used to treat Meniere’s disease. These
are prochlorperazine, cinnarizine, cyclizine, or promethazine. They help with vertigo.
Meniere’s disease
Presentation:
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear. Note: Vertigo
is usually the prominent symptom
• Episodes last minutes to hours
• MRI is normal
• Usually a female >> male ; 20-60 years old
• Typically symptoms are unilateral but bilateral symptoms may develop after a
• number of years
Treatment:
• Acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes
required
Note that vertigo and nausea can be alleviated by prochlorperazine,

cinnarizine,cyclizine, or promethazine.
Q-2
A 6 year old boy presents with a fever, cough and a sore throat. On examination,
the tonsils are erythematous but without any exudates. There are no palpable
lymphadenopathy. He had 3 similar episodes last year which were self limiting.
He has a temperature of 38.3°C. The diagnosis of tonsillitis is given. What is the
SINGLE most appropriate treatment for this child?
A. Tonsillectomy
B. Paracetamol
C. Oral penicillin
D. Oral amoxicillin
E. Prophylactic low dose penicillin
ANSWER:
Paracetamol
EXPLANATION:
This question examines your knowledge of the indications of antibiotic use in tonsillitis
and also the indications of tonsillectomy.
Antipyretic analgesics such as paracetamol and ibuprofen are of proven benefit and
recommended for relief of fever, headache and throat pain in patients with sore throat.
This child neither falls in the category for use of antibiotics or for a tonsillectomy. In this
case, the causative organism is likely viral.
Tonsillectomy
Surgery is not a treatment for the acute condition but aimed at reducing the incidenceof
recurrent infections. The indications for tonsillectomy are controversial.
Referral for tonsillectomy is indicated in children with no other explanation for recurrent
symptoms provided the frequency of symptoms is:
• More than 7 episodes per year for one year
• More than 5 per year for 2 years
• More than 3 per year for 3 years
Q-3
A new mother presents to the paediatric clinic with her 6 month old son. She
says that she is worried about his development since he does not respond to
loud noises. His motor milestones are normal and the patient’s mother says that
he vocalizes well. The pregnancy and birth were unremarkable. What is the
SINGLE best management strategy for this child?
A. Arrange hearing test

B. Assess developmental milestones
C. Reassure
D. Refer to speech therapist
E. Magnetic resonance imaging of his brain
ANSWER:
Arrange hearing test
EXPLANATION:
The Newborn Hearing Screening Programme was introduced in the UK in the early
2000’s and it is important to note that even if a newborn passes this test, they could still
develop hearing loss later on in their development. There is also the possibility that
hearing loss could be ‘missed’ during assessment due to the subjective nature of the
test.
Since this baby’s motor and verbal milestones are normal, the next best step would be
to refer this child for a hearing assessment.
Symptoms of hearing loss include, but are not limited to:

• Inattentive, not reacting when called
• Talking too loudly, listening to TV at high volume
• Unsettled at school
When should we refer for a hearing assessment?

• Any parental or professional concern
• Bacterial meningitis
• Temporal bone fracture
• Severe unconjugated hyperbilirubinaemia
• Children with delayed speech and language milestones.
Any parents who express concerns about hearing despite previous screening should
always be referred for a hearing assessment.
Q-4
A 15 year old boy injured his right ear during a rugby match. He reports pain
around the right pinna. On examination, the pinna of the right ear is red and
tender. The tympanic membrane as found to be normal. What is the SINGLE
most appropriate next step?
A. Topical gentamicin
B. Oral flucloxacillin
C. Intravenous flucloxacillin
D. Refer to ENT specialist
E. No further intervention needed
ANSWER:
No further intervention is needed
EXPLANATION:
No further intervention is needed as the tympanic membrane is normal. This is a
transient inflammation of the pinna from an injury during a hit in a rugby match. It is self
limiting and of no worry.
Q-5
An autistic 8 year old child puts a green pea in his ear while eating. Otoscopy
shows a green coloured object in the ear canal. What is the SINGLE most
appropriate approach to remove the green pea?
A. By magnet
B. Syringing
C. Removal under general anaesthesia
D. By hook
E. By instilling olive oil.
ANSWER:
Removal under general anaesthesia
EXPLANATION:
For the purpose of PLAB, whenever you see an intellectually disabled child with a
foreign object in the ear, the answer would be removal under general anaesthesia.
(Consider them to be uncooperative)
The pea is not a magnetic material and hence it cannot be removed by a magnet.
It will swell up if syringing is attempted. Irrigation with water is contra-indicated for soft
objects, organic matter or seeds (which may swell and increase the level of pain and
difficulty to remove if exposed to water).
Removal by hook is not suitable if the child is uncooperative.

Olive oil only works for ear wax or used to float an insect out by pouring olive oil into the
ear.
General anaesthesia to remove the foreign object is usually needed in this sort of
scenario. This is to avoid injury.
Referral to an ear, nose and throat specialist

Referral is indicated in the following:
• If the patient requires sedation
• If there is any difficulty in removing the foreign body
• If the patient is unco-operative.
• If the tympanic membrane has been perforated.
• If an adhesive is in contact with the tympanic membrane.
Foreign objects in the ear is a very commonly asked question in PLAB. You need to
know the management of these specific scenarios which include super glue in ear, seed
in ear, insect in ear, wax buildup, and a foreign body in ear with an uncooperative child.
Q-6
A 44 year old man presents with muffled hearing and constant high-frequency
tinnitus. He also complains of the feeling of pressure in the right ear and vertigo.
He has double vision when looking to the right. What is the SINGLE most likely
diagnosis?
A. Meniere’s disease
B. Acoustin neuroma
C. Acute labyrinthitis
D. Meningioma
E. Otosclerosis
ANSWER:
Acoustic neuroma
EXPLANATION:
Hearing loss, feeling of pressure in the ear with tinnitus, vertigo and involvement of
cranial nerve e.g. right abducens nerve are suggestive of acoustic neuroma.
ACOUSTIC NEUROMA
Acoustic neuromas (more correctly called vestibular schwannomas) account for
approximately five percent of intracranial tumours and 90 percent of cerebellopontine
angle. It causes problems by having local pressure and behaving as a space-occupying
lesion.
Features can be predicted by the affected cranial nerves
• Cranial nerve VIII: hearing loss (sensorineural deafness), vertigo, tinnitus
• Cranial nerve V: absent corneal reflex
• Cranial nerve VII: facial palsy
Bilateral acoustic neuromas are seen in neurofibromatosis type 2
Investigation
• MRI of the cerebellopontine angle is the investigation of choice.
Q-7
A 35 year old woman has dull pain in her right ear which has been present for
several weeks. The pain is located in front of the tragus of the right ear and
spreads along the cheek and mandible. Chewing increases the pain. Her
husband has mentioned that she grinds her teeth when she sleeps at night. The
ear drum appears normal and there is no discharge. What is the SINGLE most
likely diagnosis?
A. Dental caries
B. Mumps
C. Otitis media
D. Temporomandibular joint disorder
E. Trigeminal neuralgia
ANSWER:
Temporomandibular joint disorder
EXPLANATION:
The term temporomandibular disorders (TMDs) refers to a group of disorders affecting
the temporomandibular joint (TMJ), masticatory muscles and the associated structures.
One of the contributing factors is muscle overactivity which include bruxism (grinding of
teeth) which is seen in this stem.
Symptoms of temporomandibular disorders include facial pain, restricted jaw function

and joint noise. The pain is around the temporomandibular joint but is often referred to
the head, neck and ear.
Q-8
A 6 year old boy was playing at home alone when he stuck super glue into his
ear. His mother has brought him to A&E and is extremely concerned. On
inspection, the adhesive is in contact with the tympanic membrane. What is the
SINGLE most appropriate management?
A. Reassure
B. Ear irrigation
C. Refer to an Ear Nose and Throat specialist
D. Suction with a small catheter
E. Manual removal immediately
ANSWER:
Refer to an Ear Nose and Throat specialist
EXPLANATION:
Adhesives (e.g. Super Glue ®) may be removed manually within 1-2 days once
desquamation has occurred. Referral to an ear, nose and throat specialist is required if
an adhesive is in contact with the tympanic membrane.
Another foreign body which needs an urgent ENT referral is batteries that are stuck in
the auditory canal. These need to be taken out within 24 hours.
Q-9
A 29 year old diabetic woman presents to her GP surgery with a history of
gradual worsening pain in the left ear for the past 5 days. She denies hearing
loss. On examination, there is a small, red, tender mass at the outer third of the
external canal. Insertion of the otoscope causes severe localized pain. There is
no discharge seen. What is the SINGLE most likely diagnosis?
A. Chondromalacia
B. Furuncle
C. Myringitis
D. Cholesteatoma
E. Herpes zoster
ANSWER:
Furuncle
EXPLANATION:
A furuncle also known as boils is an infected hair follicle. It may be seen as a
complication of otitis externa. It is seen as an abscess of skin overlying the ear canal
cartilage. Staphylococcus aureus is the most common cause. Furuncles are typically
seen as a hard, tender, red nodule surrounding a hair follicle that enlarges over a few
days.
Diabetics or patients who are on immunosuppressive drugs are more predisposed to

furuncles.
Most furuncles in the ear canal resolve spontaneously with some requiring flucloxicillin.
Only very few of the furuncles grow larger require incision and drainage.
Q-10
A 29 year old teacher had a respiratory infection for which she was prescribed
antibiotics. A few days after she finished the antibiotic course, she rejoins
school but she has a weak, altered voice which was not present previously. What
is the SINGLE most appropriate diagnosis?
A. Recurrent laryngeal nerve palsy

B. Angioedema
C. Laryngeal obstruction
D. Laryngitis
E. Functional dysphonia
ANSWER:
Functional dysphonia
EXPLANATION:
Functional dysphonia refers to a voice disturbance that occurs in the absence of any
structural abnormality of the larynx or any cord paralysis. It is a diagnosis of exclusion.
Symptoms include vocal fatigue (voice becoming worse with use) and laryngeal
discomfort. There may be various interacting causes, such as heavy demands on the
voice, poor vocal technique and stress.
The case given above gives a history of voice overuse. This is a common problem in
some occupations such as acting and teaching. It may also follow unaccustomed voice
use, such as shouting at a football match. Vocal strain may be exacerbated when
attempting to compensate for an acute respiratory infection. Given that there is no
option to pick voice overuse and since there is no structural or neurological pathology,
functional dysphonia is the best option.
Recurrent laryngeal nerve palsy mainly presents with voice changes as well but there is
usually an obvious cause like trauma during surgery (especially thyroid surgery), tumour
spread, bulbar palsy, or penetrating wounds none of which was mentioned in this stem.
Angioedema in severe cases can cause hoarseness but it also presents with difficulty in
breathing which is not the case here.
Laryngeal obstruction like angioedema would have difficulty in breathing.
Laryngitis would have been the best option provided that the hoarseness of voice
occurred during the respiratory infection prior to treatment. Since the hoarseness of
voice occurred post treatment, it is unlikely to be laryngitis.
Q-11
A 9 year old girl has been referred for assessment of hearing as she is finding
difficulty hearing her teacher in the class. Her hearing tests show that bone
conduction is normal and symmetrical, air conduction threshold is reduced
bilaterally. Weber does not lateralize. What is the SINGLE most likely diagnosis?
A. Perforation of tympanic membrane

B. Otitis media with effusion
C. Congenital sensorineural defect
D. Otosclerosis
E. Presbycusis
ANSWER:
Otitis media with effusion
EXPLANATION:
The diagnosis here is otitis media with effusion. The hearing tests would typically show
a mild conductive hearing loss.

Also known as glue ear is common with the majority of children having at least one
episode during childhood
An important risk factor for otitis media with effusion is parental smoking. This is
extremely important to note as PLAB questions sometimes ask which would be the
SINGLE best management and then provide an option of “tell parents to stop smoking”.
One might not think this is the answer as it sounds silly, but in actual fact this is the
correct answer.
Presentation:
• Hearing loss is usually the presenting feature (glue ear is the commonest cause of
conductive hearing loss in childhood). May present as
o Listening to the TV at excessively high volumes or needing things to be repeated.
o Lack of concentration, withdrawal especially in school
• Secondary problems such as speech and language delay, behavioural or balance
problems may also be seen
• Rarely complains of ear pain
• May have prior history of infections (especially upper respiratory tract) or oversized
adenoids
Signs:
• Variable, eg retracted or bulging drum. It can look dull, grey, or yellow. There may be
bubbles or a fluid level
Diagnosis:
• Audiograms: conductive defects.
• Impedance audiometry: flat tympanogram
Treatment:
• Observation first because may resolve, monitor every 3 months (thus if a scenario is
given with a recent diagnosis of otitis media with effusion, and the question is asking
for the SINGLE best management → “Reassure and review in 3 months” would be
the best choice.
• Surgery: If persistent bilateral OME over 3 months → insert grommets
• Hearing aids: Reserve for persistent bilateral OME and hearing loss if surgery is not
accepted.
Q-12
A 5 year old child complains of sore throat and earache. He has a temperature of
38.6 C. Examination shows a enlarged hyperemic tonsils with pus. He has no
cough. He is not on any medication. What is the SINGLE most likely diagnosis?
A. Infectious mononucleosis
B. Acute tonsillitis
C. Scarlet fever
D. Acute epiglottitis
E. Acute otitis media
ANSWER:
Acute tonsillitis
EXPLANATION:
Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection.
The given case is a bacterial tonsillitis (probably caused a streptococcal infection). Note
that the pain for tonsillitis may be referred to the ears.
If the sore throat is due to a viral infection the symptoms are usually milder and often
related to the common cold.
In streptococcal infection the tonsils often swell and become coated and the throat is
sore. The patient has a temperature, foul-smelling breath and may feel quite ill. The
differences are variable and it is impossible to tell on inspection if the infection is viral or
bacterial in real life. However in PLAB, look for these main four signs that point towards
tonsillitis being caused by a bacterial infection rather than a viral infection.
4 signs:
• a high temperature
• white pus-filled spots on the tonsils
• no cough
• swollen and tender lymph nodes (glands)
Note: In this question it is unlikely to be Infectious mononucleosis (glandular fever) as it

affects teenagers most often. They may be quite unwell with very large and purulent
tonsils and a long-lasting lethargy. An enlarged spleen is classically described.
Tonsillitis
Symptoms
• Pain in the throat is sometimes severe and may last more than 48 hours, along with
pain on swallowing.
• Pain may be referred to the ears.
Signs
• The throat is reddened, the tonsils are swollen and may be coated or have white
flecks of pus on them.
• Possibly a high temperature.
• Swollen regional lymph glands.
• Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and
dysphagia.
• Examination shows intense erythema of tonsils and pharynx, yellow exudate and
tender, enlarged anterior cervical glands.
Q-13
A 33 year old man comes to the clinic complaining of hearing loss in one ear.
There is no earache, fever, vertigo, or tinnitus. On inspection, a buildup of wax is
observed. What is the SINGLE most appropriate initial management?
A. Olive oil ear drops

B. Ear irrigation
C. Refer to an Ear Nose and Throat specialist for removal of wax
D. Advise to keep ear dry
E. Removal by cotton bud
ANSWER:
Olive oil ear drops
EXPLANATION:
Ear wax softening drops are the first thing to try for a buildup of earwax. Prescribe ear
drops for 3–5 days initially, to soften wax and aid removal. Sodium bicarbonate 5%,
sodium chloride 0.9%, olive oil, or almond oil drops can be used.
If symptoms persist, consider ear irrigation
If irrigation is unsuccessful, there are three options:

• Advise the person to use ear drops for a further 3–5 days and then return for further
irrigation.
• Instill water into the ear. After 15 minutes irrigate the ear again.
• Refer to an Ear Nose and Throat specialist for removal of wax.
NICE CKS have not recommended irrigation without prior use of a softening agent
because expert opinion stated that extra force may be needed which is more likely to
cause trauma.
Advise people against inserting anything in the ear. Cotton buds, matchsticks, and hair
pins can cause the wax to become impacted by pushing it further into the canal.
Q-14
A 28 year old man has a headache that worsens on bending his head forward. He
has no nausea or vomiting. The headache tends to be at its worst first thing in
the morning and improves by the afternoon. What is the SINGLE most likely
diagnosis?
A. Chronic sinusitis
B. Trigeminal neuralgia
C. Migraine
D. Cluster headache
E. Tension headache
ANSWER:
Chronic sinusitis
EXPLANATION:
The key word here is “a headache that worsens on bending his head forward”. There
are two types of headaches which can worsen on bending. Sinus headaches and
migraines. Sinusitis, however, usually is not associated with nausea or vomiting.
Migraines, depending on severity, are often accompanied by nausea, vomiting and
sensitivity to light.
Sinus headaches are an uncommon type of headache caused by inflamed sinuses. It

happens when there is a build-up of pressure inside the sinuses and the small opening
from the sinuses to the nose becomes blocked. The pressure builds up and causes pain
behind the face and head. They are felt as a dull, throbbing pain in the upper face
especially in the area of the cheeks (maxillary sinus), bridge of the nose (ethmoid
sinus), or above the eyes (frontal sinus). It is usually on one side and tends to be worse
first thing in the morning. The pain may get worse when you move your head, strain or
bend forward. It is usually accompanied by a stuffy nose. Examination of the facial area
may reveal local tenderness, redness, swelling, and the presence of clear or discolored
nasal discharge.
Remember: Both sinus headaches and migraine headache pain often gets worse when
you bend forward. However. migraines are more severe than sinus headaches and
symptoms may include nausea and vomiting
Q-15
A 10 year old boy presents to clinic with poor grades in school and difficulty in
hearing. There has been recurrent ear infections in the past which was resolved
by medication. On examination: bone conduction is normal, air conduction is
reduced bilaterally, and there is no lateralization in the Weber’s test. There is no
pain. What is the SINGLE most likely diagnosis?
A. Acute otitis media
B. Perforation of tympanic membrane
C. Otitis media with effusion
D. Congenital sensorineural deficit
E. Otosclerosis
ANSWER:
EXPLANATION:
In PLAB 1, paediatrics ENT questions would come up occasionally. The ones to focus
on would be acute otitis media, otitis media with effusion and cholesteatoma. When
PLAB 1 has case scenarios where mothers notice their children “turning up the TV
volume” or “doing badly in school”, before thinking of behavioral / developmental
problems, go with physical problems (i.e. hearing).
This is usually the presentation of otitis media with effusion. A tympanogram would
show a hearing loss between 20 to 40 dB. If this was his first visit, reassurance and
review in 3 months would be the most appropriate. But as this problem has been
persisting for more than 12 months, a referral for a grommet insertion would be the
more appropriate choice.
Q-16
A 38 year old man was slapped over his right ear during a fight. There is blood
coming from his right external auditory canal. He describes the pain as intense
and he also has ringing in his ears. He is also noted to have decreased hearing
on that ear. What is the SINGLE most appropriate initial investigation?
A. Compute tomography
B. Magnetic resonance imaging
C. Otoscopy
D. Skull X-ray
E. Facial X-ray
ANSWER:
Otoscopy
EXPLANATION:
From the history and the mechanism of injury, one can conclude that this patient has a
perforated eardrum. Perforation of the eardrum can lead to a temporary conductive
hearing loss, tinnitus, earache and discharge of blood or mucus or both from the ear.
Nausea and vomiting may also occur. Regardless of the fact that this patient is
bleeding from the ear, the best investigation to do is still an otoscopy. Most small
perforations heal on their own however, larger perforations may need a referral to an
ENT specialist.
One would not jump right away to a computed tomography as an initial investigation for
blood in the external auditory canal. If you see blood, look for the source of the blood.
Q-17
A 15 year old boy presents to A&E with a nose bleed. The bleeding started 3
hours ago and has not stopped. His blood pressure is 115/70 mmHg, heart rate is
80 bpm and respiratory rate is 18/min. What is the SINGLE most appropriate next
course of action?
A. IV fluids
B. Lean forward, open mouth and pinch cartilaginous part of nose firmly
C. Lean backwards, ice packs and pinch base of nose firmly
D. Strat IV transexamic acid
E. Radiological arterial embolization
ANSWER:
Lean forward, open mouth and pinch cartilaginous part of nose firmly
EXPLANATION:
Epistaxis
Treatment of epistaxis varies with different literature. Thus, it is important to use the
NHS guidelines for this question.
If haemodynamically compromised
• arrange immediate transfer to A and E. Use first aid measures to control bleeding
e.g. Lean forward, open mouth. Pinch cartilaginous (soft) part of nose firmly and hold
for 10 to 15 minutes without releasing the pressure, whilst breathing through their
mouth.
If haemodynamically stable
• just use first aid measures to control bleeding
• If bleeding does not stop after 10 - 15 minutes of nasal pressure, (and still
haemodynamically stable), then do NASAL CAUTERY (using silver nitrate). If
cautery is ineffective or bleeding point cannot be seen, then NASAL PACKING.
Q-18
A 34 year old man presents with right sided facial pain felt as upper jaw pain and
located at the skin of the right cheek. He gives a history of having a cold 3 days
ago. He feels tenderness at the anterior wall below the inferior orbital margin.
What is the SINGLE most likely diagnosis?
A. Ethmoid sinus
B. Maxillary sinus
C. Septal haematoma
D. Adenoiditis
E. Allergic rhinitis
ANSWER:
Maxillary sinusitis
EXPLANATION:
The likely diagnosis here is an acute sinusitis which is an inflammation of the
membranous lining of one or more of the sinuses. Upper respiratory tract infections are
one of the predisposing factors to sinusitis which explains the history in the stem of the
cold 3 days ago.
Tenderness at the anterior wall below the inferior orbital margin can be found in
maxillary sinusitis.
The maxillary sinus is innervated by the infraorbital nerve and anterior, middle and
posterior superior alveolar nerves. Hence, pathology here may be felt as referred pain
and described as upper jaw pain, toothache or pain directly at the skin of the cheek.
Q-19
A 30 year old man was camping and an insect got stuck in his ear which he has
been unable to remove. He complains that he can still hear the buzzing in the ear.
On inspection, the insect is clearly visible in the ear canal. What is the SINGLE
most appropriate initial management?
A. 2% lidocaine
B. Ear irrigation
D. Reassure
ANSWER:
2% lidocaine
EXPLANATION:
Insects should be killed prior to removal, using 2% lidocaine.
Olive oil can also be used to float the insect out by pouring olive oil into the ear.
Q-20
A 45 year old woman presents with rotational vertigo, nausea and vomiting which
is worse when moving her head. She also had a similar episode 2 years ago.
These episodes typically follow an event of a runny nose, cough and fever.
Examination of the eardrums and cranial nerves are normal. What is the SINGLE
most likely diagnosis?
A. Acoustic neuroma
B. Meniere’s disease
C. Labyrinthitis
D. Benign paroxysmal positional vertigo
E. Vestibular neuronitis
ANSWER:
Vestibular neuronitis
EXPLANATION:
This may sound like benign paroxysmal positional vertigo but because of the history of a
runny nose, cough and fever, it is more likely to be vestibular neuritis. Vestibular
neuritis follows a viral infection and can cause vertigo, nausea and vomiting on the
movement of the head.
Vestibular neuritis
Develops over hours and resolves in days. Usually followed by a viral infection. Strictly
speaking the term means inflammation of the vestibular nerve but the aetiology is
thought to be a vestibular neuropathy.
Presentation
• Onset is usually very abrupt
• Recurrent vertigo attacks lasting hours or days
• Unsteadiness, nausea and vomiting (feel as if the room is rotating)
• Moving the head aggravates symptoms
Note: Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of
hearing symptoms (sensory type hearing loss or tinnitus). There is no hearing loss with
vestibular neuritis.
COMPARING VESTIBULAR NEURITIS AND LABYRINTHITIS

Vestibular neuritis and labyrinthitis have many similar symptoms and are sometimes
used interchangeably however, strictly speaking, vestibular neuritis is the inflammation
of the vestibular nerve whereas labyrinthtis involves vestibular nerve and the labyrinth.
Both produce vertigo and nystagmus however labyrinthitis has hearing loss and tinnitus
which is not a feature of vestibular neuritis.
Q-21
A 10 year old boy presents to his GP with a nose bleed. The bleeding started 1
hour ago and has not stopped. He is haemodynamically stable. What is the
SINGLE most appropriate next course of action?
A. Press the base of the nose

B. Press the soft parts of the nose
C. Ice packs and lean backwards
D. Start oral tranexamic acid
E. Send to A&E
ANSWER:
Press the soft parts of the noxe
EXPLANATION:
Please see Q-17
Q-22
A 52 year old woman has intermittent vertigo, tinnitus and fluctuating hearing
loss. She complains of a sensation of ear pressure. The attacks can last for 2 to
3 hours. A MRI brain scan was reported as normal. What is the SINGLE most
appropriate treatment?
A. Prochlorperazine
B. Fluphenazine
C. Vitamin A
D. Gentamicin drops
E. Aspirin
ANSWER:
Prochlorperazine
EXPLANATION:
This is a classic case of Meniere’s disease. All four clues are present: dizziness,
tinnitus, deafness, and increased feeling of pressure in the ear. Treatment is
prochlorperazine.
Meniere’s disease
Presentation:
• Dizziness, tinnitus, deafness, increased feeling of pressure in the ear. Note: Vertigo
is usually the prominent symptom
• Episodes last minutes to hours
• MRI is normal
• Usually a female >> male ; 20-60 years old
• Typically symptoms are unilateral but bilateral symptoms may develop after a
number of years
Treatment:
• Acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes
required
Note that vertigo and nausea can be alleviated by prochlorperazine, cinnarizine,

cyclizine, or promethazine.
Q-23
A 26 year old woman has become aware of an increasing right-sided hearing loss
since her last pregnancy. On otoscopy, her eardrums look normal. Her hearing
tests show bone conduction (BC) is better than air conduction (AC) in the right
ear. Weber’s test lateralizes to the right ear. What is the SINGLE most likely
diagnosis?
A. Encephalopathy
B. Functional hearing loss
C. Tympanosclerosis
D. Otosclerosis
E. Sensorineural deafness
ANSWER:
Otosclerosis
EXPLANATION:
Weber’s test lateralized to the right and bone conduction is better than air conductionon
the right. This clearly shows a conductive deafness on the right. There are no features
of encephalopathy. Tympanosclerosis has characteristic chalky white patches seen on
inspection of the eardrum. Since the eardrum here was viewed as normal, it is unlikely
to be tympanosclerosis.
The only answer left would be otosclerosis. Bone and air conduction must be tested
and in otosclerosis it typically reveals a purely conductive, predominantly low-tone loss.
Other hints in this stem are:
• Female gender – otosclerosis usually occurs in females (2:1 female:male ratio)

• Pregnancy – pregnancy accelerates the progression of osteosclerosis
Rinne's and Weber's test

Performing both Rinne's and Weber's test allows differentiation of conductive and
sensorineural deafness.
Rinne's test
A tuning fork is placed over the mastoid process until the sound is no longer heard,
followed by repositioning just over external acoustic meatus
• Note that air conduction (AC) is normally better than bone conduction (BC) (Positive
Rinne's test)
• If BC > AC, then the patient has conductive deafness (Negative Rinne’s test)
• (Abnormal Rinne’s test)
Note that the words positive and negative are used in a somewhat confusing fashion
here, as compared to their normal use in medical tests. Positive or negative in this case
means that a certain parameter that was evaluated was present or not. In this case, that
parameter is whether air conduction (AC) is better than bone conduction (BC).
Thus, a "positive" result indicates the healthy state, in contrast to many other medical
tests. Therefore, some prefer to avoid using the term 'positive' or 'negative', and simply
state if the test was normal or abnormal e.g. 'Rinne's test was abnormal in the right ear,
with bone conduction greater than air conduction'.
Weber's test
A tuning fork is placed in the middle of the forehead equidistant from the patient's ears.
The patient is then asked which side is loudest
• If sound is localised to the unaffected side, then this is unilateral sensorineural
deafness
• If sound is localised to the affected side, then this is unilateral conductive deafness
Example
If Weber’s test localises to the right side. It can either be right conductive deafness OR
left sensorineural deafness. A Rinne’s test would be able to confirm if it is a right
conductive deafness.
OTOSCLEROSIS
In otosclerosis, there is a pathological increased bony turnover leading to sclerosis and
failure of the sound conduction mechanism. This is due to ankylosis of the stapes
footplate in the fenestra ovalis of the cochlea. This reduces normal sound transmission
resulting in a conductive deafness.
Otosclerosis is the commonest cause of progressive deafness in young adults. It

usually presents between 15 and 45 years of age.
Genetic factors are involved, so the condition often (but not always) runs in families.
The family history is especially important to note as it is commonly given in the stem if
the question writers want you to pick otosclerosis.
It is bilateral in 80% of cases, although it is not uncommon for one ear to be worse than
the other.
Untreated, the deafness gradually worsens. Other symptoms of otosclerosis include

tinnitus and vertigo.
It is progressive and there is no curative treatment at the moment. The management

involves either surgery (stapedectomy or stapedotomy, with the insertin of a prosthesis)
or bilateral hearing aids for those not fit for surgery.
Key features for otosclerosis:

• Main symptoms are progressive hearing loss and tinnitus
• Majority of the time it is bilateral
• Conductive hearing loss (where the cochlea is involved there may be a mixed
conductive/sensory pattern of hearing loss)
• A family history of hearing loss
Q-24
A 45 year old man who works in a busy shipyard has been experiencing ringing in
his ears and depression of sound that began soon after the onset of tinnitus.
This has been going on over the past few months with worsening severity. He
experiences difficulty in understanding what is said over the phone or when a few
people are talking all at once in a large room. He feels that sounds seem to be
gradually more muffled. What is the SINGLE most likely term to describe his
condition?
A. Bilateral sensorineural hearing loss

B. Bilateral conductive hearing loss
C. Unilateral sensorineural hearing loss
D. Unilateral conductive hearing loss
E. Mixed hearing loss
ANSWER:
Bilateral sensorineural hearing loss
EXPLANATION:
Noise-induced hearing loss (NIHL) is hearing impairment from exposure to loud sound.
In this case since the hearing loss is resulting from noise that occurs at his workplace,
the shipyard, it is referred to as occupational hearing loss. When there is excessive
loud noise, the force leads to cellular metabolic overload, and damage to hair cells in
the inner ear which can caue high-frequency sensorineural hearing loss. This is most
often bilateral. This patient should be referred to an audiologist who would be able to
confirm a sensorineural hearing loss and provide hearing aids.
Q-25
A 4 year old girl has a painful right ear. She is irritable and has been crying and
coughing. She has a temperature of 38.8 C. Otoscopy reveals a tympanic
membrane which appears red. There is no light reflex visible on the tympanic
membrane. What is the SINGLE most likely diagnosis?

B. Herpetic infection of the ear
C. Furuncle
D. Perforation of the eardrum
E. Otitis externa
ANSWER:
Acute otitis media
EXPLANATION:
The diagnosis can be seen with the examination of the ear. A red tympanic membrane
that is bulging is classical for otitis media. We know that the membrane is bulging
because there is a loss of light reflex. The light reflex (cone of light) is seen as a cone-
shaped reflection in the anterior inferior quadrant of the tympanic membrane. The
absence of the light reflex occurs when there is a distortion of the shape of the tympanic
membrane such as a bulging membrane due to an increase of inner ear pressure seen
in otitis media.
Acute otitis media in children

Acute otitis media is acute inflammation of the middle ear and may be caused by
bacteria or viruses.
Features
• Rapid onset of pain (younger children may pull at the ear)
• Fever
• Irritability
• Coryza
• Vomiting
• Often after a viral upper respiratory infection
• A red, yellow or cloudy tympanic membrane or bulging of the tympanic membrane.
• An air-fluid level behind the tympanic membrane
• Discharge in the auditory canal secondary to perforation of the tympanic membrane
• Perforation of the eardrum often relieves pain. This is because bulging of the
tympanic membrane causes the pain.
OTITIS MEDIA VS OTITIS EXTERNA
Otitis media Otitis externa

Risk factors • Younger age • Swimming
• High environmental humidity
Features • May be seen with a bulging • Serous discharge

tympanic membrane without • Starts with an itch followed by
discharge or purulent discharge pain.
with a ruptured tympanic
membrane
• Starts with pain in the ear
followed by a popping sensation
of the ear with complete
resolution of pain. This is
followed by discharge.
• Follows an upper respiratory
infection
Treatment • Usually conservative as aetiology • Combinations of topical
is usually viral acetic acid, topical
• If bacterial aetiology is aminoglycoside and
suspected, prescribe oral topical corticosteroids
amoxicillin
If you are treating an otitis externa but suspect there may be a tympanic membrane
perforation, aminoglycosides ear drops are not the best choice as it is ototoxic. In these
cases, ciprofloxacin drops would be used however it is not currently licensed for this
indication.
Q-26
A 41 year old man presents with longstanding foul smelling brown ear discharge
and progressive hearing loss of his right ear. The discharge has persisted
despite three courses of antibiotic ear drops. Otoscopy shows perforation of the
pars flaccida. A pearly white soft matter is seen at the posterior margin of the
perforation. What is the SINGLE most likely diagnosis?
A. Acute Suppurative Otitis Media

B. Chronic Suppurative Otitis Media
C. Acquired cholesteatoma
D. Congenital cholesteatoma
E. Barotrauma
ANSWER:
Acquired cholesteatoma
EXPLANATION:
A cholesteatoma represents a destructive expanding growth consisting of keratinising
squamous epithelium in the middle ear and/or mastoid process much like an abnormal
collection of skin cells inside your ear that left untreated can continue to grow and
damage the bones of the middle ear (ossicles)
Physical findings often show a canal filled with mucus, pus and granulation tissue. A
white mass behind the tympanic membrane is one of the other features in 90% of cases
of acquired cholesteatoma, the tympanic membrane is perforated.
Congenital cholesteatoma is incorrect. Perforation is seen less commonly with

congenital cholesteatoma and there is often no history of recurrent suppurative ear
disease unlike acquired cholesteatoma.
CHOLESTEATOMA
The term cholesteatoma is a misnomer as it is actually neither cholesterol nor a tumour.
Cholesteatoma is a destructive and expanding growth consisting of keratinizing
squamous epithelium in the middle ear and/or mastoid process. Think of cholesteatoma
as an uncommon abnormal collection of skin cells inside your ear that left untreated can
continue to grow and damage the bones of the middle ear (ossicles).
Small lesions are associated with a progressive conductive hearing loss but, as the
lesion grows and erodes into adjacent structures, there may be additional features such
as vertigo, headache and facial nerve palsy
It can be either congenital or acquired.
Acquired cholesteatoma
• Occurs following repeated ear infections. Note they are usually poorly responsive to
antibiotic treatment
• Frequent painless otorrhoea which may be foul-smelling
• Progressive, unilateral conductive hearing loss
• Tympanic membrane perforation is seen in around 90% of cases or retracted
tympanum
• Signs on otoscopic exam:
o A retraction pocket in attic or posterosuperior quadrant of tympanic membrane
o Granular tissue
o White mass behind the eardrum
o Purulent drainage
Congenital cholesteatomas
• Presents in childhood (6 months to 5 years) but may occasionally present much
later, in adulthood
• Often no history of recurrent suppurative ear disease, previous ear surgery or
tympanic membrane perforation
• May be an incidental finding on routine otoscopy of an asymptomatic child
• Seen as a pearly white mass behind an intact tympanic membrane
• Signs on otoscopic exam:
o Spherical white mass behind intact membrane
Remember: Cholesteatoma is suggested by the following:

• Foul discharge
• Deafness
• Headache
• Ear pain
• Facial paralysis
• Vertigo
Q-27
A 48 year old man has a lump on his mandible. It has rapidly increased in size
over the past 8 months. On examination, there is an induration of the skin
overlying the mass. The mass is free and mobile. What is the SINGLE most
appropriate investigations?
A. Fine needle aspiration (FNA) cytology

B. Computed tomography
C. Salivary immunoglobulin M (IgM)
D. Magnetic resonance imaging
E. Erythrocyte sedimentation rate (ESR)
ANSWER:
Fine needle aspiration (FNA) cytology
EXPLANATION:
Submandibular neoplasms often appear with diffuse enlargement of the gland. Any
masses of this sort need to be investigated. In fact, any salivary gland swelling that is
present for more than 1 month needs to be investigated or removed. Ultrasound-guided
fine needle aspiration (FNA) cytology is used to obtain cytological confirmation.
Q-28
A 40 year old man with a 25 year history of smoking presents with progressive
hoarseness of voice, difficulty swallowing and episodes of haemoptysis. He
mentioned that he used to be a regular cannabis user. What is the SINGLE most
likely diagnosis?
A. Nasopharyngeal cancer
B. Pharyngeal carcinoma
C. Sinus cancer
D. Laryngeal cancer
E. Hypopharyngeal tumour
ANSWER:
Laryngeal cancer
EXPLANATION:
The history of cannabishere is of no value. It has no relation to laryngeal cancer or any
of the above cancers.
Given the history of smoking, hoarseness of voice, dysphagia, and haemoptysis, the
likely diagnosis is laryngeal cancer.
Laryngeal Cancer
Risk factors
• Smoking is the main avoidable risk factor for laryngeal cancer
Presentation
• Chronic hoarseness is the most common early symptom.
• Other symptoms of laryngeal cancer include pain, dysphagia, a lump in the neck,
sore throat, earache or a persistent cough.
• Patients may also describe breathlessness, aspiration, haemoptysis, fatigue and
weakness, or weight loss.
Q-29
A 6 year old girl has a left earache for 4 days. The earache then subsided 2 hours
ago with the onset of a purulent discharge which relieved the pain. Her
temperature is 39.2 C. What is the SINGLE most appropriate antibiotic to
prescribe?
A. Amoxicillin
B. Ciprofloxacin
C. Clindamycin
D. Erythromycin
E. Flucloxacillin
ANSWER:
Amoxicillin
EXPLANATION:
This is the picture of Acute Otitis Media which has led to tympanic membrane
perforation.
Sometimes a child may report that the pain suddenly settles. This is followed by
discharge. The reason that the pain suddenly settles is that the tympanic membrane
has perforated, releasing the pressure immediately.
Otitis media can be bacterial or viral but most are self limiting and do not require
antibiotics. If an antibiotic is required, prescribe a five-day course of amoxicillin. For
children who are allergic to penicillin, prescribe a five-day course of erythromycin or
clarithromycin. The most common bacterial pathogens are Haemophilus influenzae,
Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes of
which amoxicillin would be suitable. The most common viral pathogens are respiratory
syncytial virus (RSV) and rhinovirus.
Q-30
A 66 year old male presents with painful swallowing. He describes it as a burning
sensation that radiates to the back everytime he swallows fluid or food. What is
the SINGLE most likely causative organism?
A. Neisseria meningitides
B. Cryptococcus neoformans
C. Candida albicans
D. Isospora belli
E. Mycobacterium avium
ANSWER:
Candida albicans
EXPLANATION:
Given the options, Candida albicans would be the only culprit that would cause
odynophagia.
Oesophageal candidiasis
Presentation
• Dysphagia
• Odynophagia (pain on swallowing) food or fluids
Q-31
A 7 year old boy is brought to clinic by his mother. His mother complains that he
has been getting in trouble in school because he is inattentive in class. The
mother also mentions that he sits close to the television at home. These
problems have been going on for more than 12 months. There is no pain or fever.
A tympanogram highlights conductive hearing loss at 30-dB. What is the SINGLE
most appropriate management?
A. Grommet insertion
B. Reassure and review in 3 months
C. Hearing aids
D. Adenoidectomy
E. Refer to child psychologist
ANSWER:
Grommet insertion
EXPLANATION:
This is usually the presentation of otitis media with effusion. A tympanogram would
show a hearing loss between 20 to 40 dB. If this was his first visit, reassurance and
review in 3 months would be the most appropriate. But as this problem has been
persisting for more than 12 months, a referral for a grommet insertion would be the
more appropriate choice.
Q-32
A 52 year old patient is complainingof vertigo whenever she moves sideways on
the bed while lying supine. She would feel as if the room is spinningand she
would feel nauseous. This goesaway after a few minutes but returns when she
moves her head. What is the SINGLE most appropriate test to perform?
A. Hallpike’s manoeuvre
B. Sanding and lying blood pressure
C. Neurological examination
D. Carotid Doppler
E. Compute tomography of head
ANSWER:
Hallpike’s manoeuvre
EXPLANATION:
A classical scenario of benign paroxysmal positional vertigo. A Dix-Hallpike test would
help provide the diagnosis> The Dix-Hallpike manoeuvre would be positive if the
patient reports reproductin of vertigo and nystagmus is seen.
Whilst standing and lying blood pressure is also important in clinical practice to perform
to exclude orthostatic hypotension, the description of symptoms here describe benign
paroxysmal positional vertigo clearly and not orthostatic hypotension.
BENIGN PAROXYSMAL POSITIONAL VERTIGO

• one of the most common causes of vertigo encountered.
• Characterised by the sudden onset of dizziness and vertigo triggered by changes in
head position.
Presentation:
• Vertigo usually occurs on turning over in bed or lyind down (basically any
acceleration of the head)
• Each episode typically lasts 10-20 seconds but can last a few minutes
• Nausea during episodes
Diagnosis:
• Hallpike's Manoeuvre positive
Treatment:
• Mostly spontaneous resolution with exacerbations
• Epley’s manoeuvre
o A repositioning technique used to reposition otoliths back into the utricles from
the posterior semicircular canals
Q-33
A 33 year old tennis player has to stop playing tennis competetively because she
has recurrent vertigo attacks every time she plays tennis. The vertigo attacks
started after a history of a runny nose, cough and fever. Her hearing is not
affected. What is the SINGLE most likely diagnosis?
A. Acoustic neuroma
C. Labyrinthitis
D. Benign paroxysmal positional vertigo
E. Vestibular neuritis
ANSWER:
Vestibular neuritis
EXPLANATION:
This may sound like benign paroxysmal positional vertigo but because of the history of
runny nose, cough and fever, it is more likely to be vestibular neuritis. Vestibular
neuritis follows a viral infection and can cause vertigo, nausea and vomiting on
movement of the head.
Vestibular neuritis
Develops over hours and resolves in days. Usually followed by a viral infection. Strictly
speaking the term means inflammation of the vestibular nerve but the aetiology is
thought to be a vestibular neuropathy.
Presentation
• Onset is usually very abrupt
• Recurrent vertigo attacks lasting hours or days
• Unsteadiness, nausea and vomiting (feel as if the room is rotating)
• Moving the head aggravates symptoms
Note: Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of
hearing symptoms (sensory type hearing loss or tinnitus). There is no hearing loss with
vestibular neuritis.
COMPARING VESTIBULAR NEURITIS AND LABYRINTHITIS

Vestibular neuritis and labyrinthitis have many similar symptoms and are sometimes
used interchangeably however, strictly speaking, vestibular neuritis is the inflammation
of the vestibular nerve whereas labyrinthitis involves vestibular nerve and the labyrinth.
Both produce vertigo and nystagmus however labyrinthitis has hearing loss and tinnitus
which is not a feature of vestibular neuritis.
Q-34
A 30 year old lady has epistaxis for 30 minutes. Blood results shows:
Haemoglobin 122 g/L

White cell count 8 x 109/L
Platelets 200 x 109/L
Prothrombin time (PT), Activated partial thromboplastin time (APTT) and bleeding
time is normal
What is the SINGLE most likely cause of the bleed?

A. Platelet disorder
B. Clotting factor deficiency
C. Sepsis
D. Anatomical defect
E. Warfarin use
ANSWER:
Anatomical defect
EXPLANATION:
All her blood work is normal. This is likely a anatomical defect.
Trauma to the nose is the most common cause. Nose picking, insertion of foreign
bodies and excessive nose blowing may also be seen as trauma.
Q-35
An 8 year old boy who has recently returned from Spain complains of severe pain
in one ear. On examination, pus is seen in the auditory canal. The tympanic
membrane looks normal. What is the SINGLE most appropriate treatment?
A. Topical gentamicin
B. Amoxicillin orally
C. Analgesia
D. Erythromycin orally
E. Microsuction
ANSWER:
Topical gentamicin
EXPLANATION:
The diagnosis here is otitis externa.
Symptoms of otitis externa include minimal discharge, itch, pain and tragal tenderness
due to an acute inflammation of the skin of the meatus
This is a frequent question and the treatment options include: Topical gentamicin or
Topical gentamicin with hydrocortisone. Both are correct. An example is Gentisone-HC
which contains both gentamicin and hydrocortisone appropriate for most bacteria
including anaerobes such as pseudomonas which commonly affect the external ear.
Note that gentamicin and hydrocortisone is used less commonly in practice for otitis
externa nowadays but it is still going to be the answer if asked. Public Health England
suggest using acetic acid 2% 1 spray tds for 7 days as first line and neomycin sulphate
with corticosteroid 3 drops tds for 7 to 14 days as second line. Majority of general
practitioners would follow Public Health England’s regulations.
Q-36
A 9 year old girl has been increasing the volume of the television to an excessive
level. Her parents complain that she needs them to repeat themselves
constantly. On examinaiton, bone conduction is normal, air conduction is
reduced bilaterally. What is the SINGLE most likely diagnosis?
A. Perforation of tympanic membrane

B. Otitis media with effusion
C. Congenital sensorineural deficit
D. Otosclerosis
E. Presbycusis
ANSWER:
Otitis media with effusion.
EXPLANATION:
The diagnosis here is otitis media with effusion. The hearing tests would typically show
a mild conductive hearing loss.
Q-37
A 25 year old woman complains of dizziness, nausea, and anxiety which keeps
coming from time to time. She notices that the attacks are associated with
sudden change in posture and these episodes last only a few seconds. She
describes the sensation as “the room spinning around her”. What is the SINGLE
A. Panic disorder
B. Carotid sinus syncope
C. Benign paroxysmal positional vertigo
D. Vertebrobasilar insufficiency
E. Postural hypotension
ANSWER:
Benign paroxysmal postiional vertigo
EXPLANATION:
The term she uses “the room spinning around her” is a classic description of vertigo.
The fact that she notices this when changing posture tells us that it is likely due to a
change of head position which is classic for benign paroxysmal positional vertigo.
Q-38
A 7 year old boy presents with a fever, severe ear ache, and vomiting. Tonsillitis
was noted on examination. Otoscopy reveals a red bulging tympanic membrane.
His temperature is 38.5 C. On examination, cervical lymphadenopathy was
palpated. What is the SINGLE most likely diagnosis?
A. Otitis externa
B. Acute otitis media
C. Referred pain from teeth
D. Chronic suppurative otitis media
E. Mastoiditis
ANSWER:
Acute otitis media
EXPLANATION:
Acute otitis media may occur after a viral upper respiratory tract infection which in this
case is the tonsillitis.
Cervical lymphadenopathy which is seen in this stem is seen commonly with tonsillitis
and it is one of the signs that point you towards a bacterial aetiology.
Q-39
A 52 year old with poorly controlled diabetes mellitus presents to his GP with
severe pain in the ear and an intense headache. On examination, his skin around
the ear is black in colour and there is a foul smelling discharge coming from the
ear. He is also noted to have conductive hearing loss. Examination of the cranial
nerves reveal a facial nerve palsy. What is the SINGLE most likely diagnosis?
A. Carbuncle
B. Ramsay Hunt syndrome
C. Malignant otitis externa
D. Cholesteatoma
E. Furuncle
ANSWER:
Malignant otitis externa
EXPLANATION:
Malignant otitis externa is an aggressive infection rather than a malignancy, or cancer.
It is rare. In some cases, the infection can spread to the outer ear and surrounding
tissue, including the bones of the jaw and face. Despite the term “malignant” being
used, it is NOT cancerous.
Conductive hearing loss and foul-smelling purulent otorrhoea is also one of the features
in malignant otitis externa.
Risk factors for malignant otitis externa include diabetes and a weakened immune
system.
Without treatment, malignant otitis externa can be fatal with a 50% mortality rate.
Presentations like this need an urgent referral to ENT.
Q-40
A 29 year old man with a medical history that includes late onset asthma attends
clinic with rhinorrhoea and bilateral painless nasal obstruction. He complains of
reduced sense of smell. What is the SINGLE most likely diagnosis?
A. Septal abscess
B. Septal haematoma
C. Nasal polyp
D. Atrophic rhinitis
E. Allergic rhinitis
ANSWER:
Nasal polyp
EXPLANATION:
Nasal polyps
• Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or
paranasal sinuses.
Note that nasal polyps tend to be bilateral.
Associations
• Asthma
• Aspirin sensitivity
It is particularly important to remember the association with asthma.
Note: The association of asthma, aspirin sensitivity and nasal polyps is known ans
Samter’s triad.
Presentation
• Nasal obstruction
• Rhinorrhoea
• Anosmia (loss of smell)
Q-41
A 6 year old boy was playing in the playground when he stuck a seed into his ear.
He has been unable to remove it. On inspection, the seed is clearly visible in the
ear canal. What is the SINGLE most appropriate management?
A. 2% lidocaine
B. Ear irrigation
C. Refer to an Ear, Nose and Throat specialist
ANSWER:
Suction with a small catheter
EXPLANATION:
Irrigation with water is contra-indicated for soft objects, organic matter or seeds (which
may swell and increase the level of pain and difficulty to remove if exposed to water)
Suction with a small catheter held in contact with the object may be effective.
Q-42
A 5 year old girl has been reported by her parents to be increasing the volume of
the television to an excessive level. A hearing test conducted at school schows a
symmetric loss of 40 dB. A grey bulging drum is seen on otoscopy on both ears.
A. Otitis media with effusion

B. Otitis externa
C. Cholesteatoma
D. Otosclerosis
E. Congenital sensorineural deficit
ANSWER:
EXPLANATION:
The child’s hearing loss and increasing the TV volume suggests that she has otitis
media with effusion. This is supported by the otoscopy findings.
Q-43
A 7 year old boy is brought to clinic by his mother. She says that he is always
turning up the TV volume and she has to shout to get his attention. There has
been recurrent eatr infections in the past which was resolved by medication. On
examination, a bulging drum is noticed. There is no pain or fever. What is the
SINGLE most appropriate management?
A. Grommet insertion
B. Reassure and review in 3 months
C. Hearing aids
D. Adenoidectomy
E. Antibiotics
ANSWER:
Reassure and review in 3 months.
EXPLANATION:
This is usually the presentation of otitis media with effusion. As this is his first visit,
reassurance and review in 3 months would be the most appropriate.
Q-44
An 11 year old girl presents to the clinic with hoarseness of voice. She is a
known case of bronchial asthma and has been on oral steroids for half a year.
What is the SINGLE most likely cause of her hoarseness of voice?
A. Laryngeal candidiasis
B. Infective tonsillitis
C. Laryngeal edema
D. Allergic drug reaction
E. Ludwig’s angina
ANSWER:
Laryngeal candidiasis
EXPLANATION:
Steroids predispose to fungal infection and can cause laryngeal candidiasis which
results in hoarseness.
Q-45
A 17 year old woman, with no previous history of ear complaints, presents with a
two day history of severe pain in the right ear which is extremely tender to
examine. Prior to the onset of pain, she was complaining of itch in her right ear.
On examination, there is tenderness with movement of the tragus. Otoscopy
reveals a serous discharge seen in the auditory canal. What is the SINGLE most
likely diagnosis?
A. Chondromalacia
B. Furuncle
C. Myringitis
D. Otitis externa
E. Otitis media
ANSWER:
Otitis externa
EXPLANATION:
Otitis externa is difficult to examine because of tenderness. Typically there is pain when
moving the tragus.
Serous discharge is more typical for an external ear infection rather than middle ear
infection. In middle ear infections, the discharge is usually thick. Itching is also a
common symptom with otitis externa which usually occurs before the pain begins.
Occasionally, hearing loss and fever may be seen in the stem.
Q-46
A 45 year old male presents with a whitish-grey opaque areas with red inflamed
patches on his tongue. These patches are unable to be scraped off. What is the
SINGLE most likely diagnosis?
A. Kaposi’s sarcoma
B. Basal cell carcinoma
C. Aphthous ulcer
D. Oral thrush
E. Leukoplakia
ANSWER:
Leukoplakia
EXPLANATION:
Leukoplakia
• Seen as white thickening of the oral mucosa
• The key word that question writers would have to give is that “the white patch that
adheres to oral mucosa cannot be removed by rubbing”
• These should be biopsied as it is premalignant
Q-47
A 12 year old boy presents with right sided hearing loss and facial drooping on
the right side. He has a headache and feels dizzy. On examination, both ears
appear normal with an intact eardrum. Rinne’s test was found to be normal.
Weber lateralized to the left. What is the SINGEL most likely diagnosis?
A. Bell’s palsy
B. Lyme disease
C. Acoustic neuroma
D. Pituitary adenoma
E. Glioma
ANSWER:
Acoustic neuroma
EXPLANATION:
The symptoms here describe a facial nerve and vestibulocochlear nerve involvement.
This can occur from a space-occupying lesion like an acoustic neuroma.
Q-48
A 45 year old man has noticed difficulty hearing over the telephone. His hearing
has been progressively getting worse over the last few years. He is concerned
because his father has had similar problems around his age. Rinne’s and
Weber’s test demonstrate conductive hearing loss. An audiogram shows
moderate hearing loss in both ears across all frequencies. What is the SINGLE
A. Acoustic neuroma
C. Glue ear
D. Otosclerosis
E. Presbycusis
ANSWER:
Otosclerosis
EXPLANATION:
This patient has conductive hearing loss. With that information, we are able to rule out a
few options here. Acoustic neuroma, and presbycusis present with sensorineural
hearing loss, so we can cross those out right away. Meniere’s disease classically has
four clues which are present in the stem: dizziness, tinnitus, deafness, and increased
feeling of pressure in the ear (Note: Vertigo being the prominent symptom). Glue ear
(Otitis media with effusion) is more common in children. WIth the given family history,
otosclerosis fits the best.
Q-49
A 10 year old child developed fever, severe earache and tonsillitis following an
upper respiratory infection. On otoscopy, the tympanic membrane is distinctly
red. What is the most likely diagnosis?

B. Otitis externa
C. Glue ear
D. Meningitis
E. Vestibular neuritis
ANSWER:
Acute otitis media
EXPLANATION:
In older children and adults, AOM usually presents with earache. If the child was
younger, he may pull or rub his ear, or may have nonspecific symptoms such as fever,
irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea.
Q-50
A 6 year old Down syndrome boy was playing at home alone when he stuck a
small piece of toy into his ear. His mother has brought him to a GP clinic and is
extremely concerned. On inspection, a small foreign object is visible. The child
is uncooperative and does not understand why his mother has brought him here.
What is the SINGLE most appropriate management?
A. Olive oil ear drops

B. Ear irrigation
E. Manual removal immediately using forceps
ANSWER:
Refer to an Ear Nose and Throat specialist
EXPLANATION:
This patient is uncooperative and needs an ENT referral. General anaesthesia to
remove the foreign object is usually needed in this sort of scenario.
Referral to an ear, nose and throat specialist

Referral is indicated in the following:
• If the patient requires sedation.
• If there is any difficulty in removing the foreign body.
• If the patient is unco-operative.
• If the tympanic membrane has been perforated.
• If an adhesive is in contact with the tympanic membrane.
Q-51
A 5 year old girl has had an upper respiratory tract infection for 3 days and has
been treated with paracetamol by her mother. In the last 12 hours, she has been
irritable and with severe pain in her right ear. She has a temperature of 38.3 C.
A. Herpes zoster infection

B. Impacted ear wax
C. Mumps
D. Acute otitis media
E. Perforation of eardrum
ANSWER:
Acute otitis media
EXPLANATION:
Please see Q-25
Q-52
An 8 year old boy was brought by his mother complaining that her child seems to
be watching the television at very high volumes. He lacks concentration and is
socially withdrawn. He would prefer to read books indoors rather than play
outdoors. What is the SINGLE most likely findingto be exptected on an
otoscopy?
A. Flamingo pink tympanic membrane

B. Attic perforation
C. A bluish grey tympanic membrane with an air fluid level
D. Inflamed tympanic membrane with cartwheel appearance of vessels
E. Red and inflamed tympanic membrane
ANSWER:
A bluish grey tympanic membrane with an air fluid level
EXPLANATION:
Please see Q-11
Q-53
A 48 year old man has difficulty hearing. Bone conduction is better than air
conduction in the left ear. The sound was localised towards the left side on
Weber’s test. What is the SINGLE most likely diagnosis?
A. Right sensorineural deafness

B. Left sensorineural deafness
C. Right conductive deafness
D. Left conductive deafness
E. Bilateral conductive deafness
ANSWER:
Left conductive deafness
EXPLANATION:
“Bone conduction is better than air conduction in the left ear” – tells us that patient has
conductive deafness.
“The sound was localised towards the left side on Weber’s test” – as sound is localised
to the affected side, then this is unilateral conductive deafness.
Q-54
A 4 year old girl presents with an anterior midline lump on her neck. It is
painless, smooth and measures 1.5 cm. The swelling tends to move upwards
when she protrudes her tongue. What is the SINGLE most likely diagnosis?
A. Thyroglossal cyst
B. Goitre
C. Pharyngeal pouch
D. Thyroid cancer
E. Lipoma
ANSWER:
Thyroglossal cyst
EXPLANATION:
Thyroglossal cysts
Thyroglossal cysts represent the most common congenital anomaly of the neck and
account for 2-4% of all neck masses. They form along the embryological tract of the
thyroid. They usually present as fluctuant swellings in the midline of the neck along the
line of thyroid descent. These cyst tend to move upwards on tongue protrusion because
they are attached to the thyroglossal tract which attaches to the larynx by the
peritracheal fascia. They are painless and mobile but can become painful if infected.
Q-55
A 55 year old man presents with swelling at the angle of the mandible which is
progressively increasing in size over the past 6 months. It is painless, firm and
mobile. What is the SINGLE most likely diagnosis?
A. Benign parotid tumour

B. Mandible tumour
C. Tonsillar carcinoma
D. Parotitis
E. Sjogren’s syndrome
ANSWER:
Benign parotid tumour
EXPLANATION:
The description of a mobile mass fits a benign parotid tumour such as pleomorphic
adenoma. A mandibular tumour or tonsillar carcinoma would not be described as
mobile. Parotitis is unlikely as parotitis is described as a painful and tender mass at the
angle of the jaw. Sjögren's syndrome does involve parotid gland enlargement and
occasional tenderness but no other features of Sjögren's syndrome were given in this
stem such as dryness in the eyes or mouth. Therefore benign parotid tumour is still
more likely than Sjögren's syndrome.
PLEOMORPHIC ADENOMA
• Also called benign mixed tumour
• It is the most common tumour of the parotid gland and causes over a third of
submandibular tumours
• The most common salivary gland tumour
Features
• Presents around middle age
• Slow-growing and asymptomatic
• Solitory
• Painless
• Usually mobile
• Firm single nodular mass
Although pleomorphic adenomas are classified as a benign tumors, they have the
capacity to undergo malignant transformation.
Treatment involves removing by superficial parotidectomy or enucleation
Q-56
A 75 year old man presents with symptoms of progressive sensorineural hearing
loss on the right. He also complains of dizziness and tinnitus. What is the
SINGLE most appropriate investigation?
A. Computed tomography of internal auditory meatus

B. Nuclear imaging of brain
C. Magnetic resonance imaging of internal auditory meatus
D. Ultrasound scan and fine needle aspiration
E. X-ray skull
ANSWER:
Magnetic resonance imaging of internal auditory meatus
EXPLANATION:
Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve. An
acoustic neuroma would be up on the list of differentials. An MRI of the internal auditory
meatus will show a benign tumour in the cerebellopontine angle.
Sometimes, in the stem, they would include facial palsy as a feature.
Q-57
A 45 year old man presents with hearing loss and tinnitus in the right ear. A 512
Hz tuning fork is used which highlights Rinne’s test having AC > BC bilaterally.
Weber test lateralizes to the left. What is the SINGLE next best investigation?
A. Computed tomography
B. Magnetic resonance imaging
C. Angiogram
D. Otoscopy
E. Oto-acoustic emissions
ANSWER:
Magnetic resonance imaging
EXPLANATION:
AC > BC indicates Rinne positive (i.e. deafness is not conductive). It is important to note
that the hearing loss is on right side. Weber lateralized to left. Weber lateralizes to the
same side if there is conductive deafness and to opposite if there is sensorineural
deafness. It is quite obvious that the deafness of right ear is sensorineural deafness for
which magnetic resonance imaging brain is the next best investigation.
Sensorineural hearing loss refers to problems occurring in the cochlea, cochlear nerve
or brain stem, resulting in abnormal or absent neurosensory impulses. MRI scan can be
used to identify gross structural causes of hearing loss. They are useful in cases where
a tumour is suspected or to determine the degree of damage in a hearing loss caused
by bacterial infection or auto-immune disease.
Q-58
A 47 year old man has difficulty hearing on his right ear. Air conduction (AC) is
better than bone conduction in both ears. The sound was localised towards the
left side on Weber’s test. What is the SINGLE most likely diagnosis?
A. Right sensorineural deafness

B. Left sensorineural deafness
C. Right conductive deafness
D. Left conductive deafness
E. Bilateral sensorineural deafness
ANSWER:
Right sensorineural deafness
EXPLANATION:
“Air conduction (AC) is better than bone conduction in both ears” – tells us that this is a
normal finding.
“The sound was localised towards the left side on Weber’s test” – tells us that there is
unilateral sensorineural deafness on the opposite side of where the sound localises to
which is right sensorineural deafness.
Q-59
A mother of a 2 day old infant is concerned about the infant’s ability to hear. The
mother is still in the hospital with her newborn recovering from her caesarian
section. The infant is otherwise well and born with good Apgar scores. The
concern from the mother comes from the fact that the mother has had a moderate
degree of permanent hearing loss during her teenage years and has to wear
hearing aids. What is the SINGLE most appropriate test to perform?
A. Magnetic resonance imaging of the head

B. Distraction test
C. Automated auditory brainstem response (AABR)
D. Pure tone audiogram
E. Reassure, no test required at this stage
ANSWER:
Automated auditory brainstem (AABR)
EXPLANATION:
Hearing screening is offered to all babies in England within 4 to 5 weeks of birth.
Babies who were born in the hospital are normally given a newborn hearing test before
they are discharged otherwise it would be done in the first few weeks of life by a health
visitor.
The hearing screening programme offers 2 types of test:

• Automated otoacoustic emission (AOAE)
• Automated auditory brainstem response
Automated otoacoustic emission (AOAE) test takes a few minutes. A soft-tipped

earpiece is placed in the newborn’s ear and clicking sounds are played. Vibration of the
hair cells in response to noise generates acoustic energy which is detected by a
microphone in the external meatus. If AOAE test is performed and there is no clear
response in one or both eares, then the automated auditory brainstem response
(AABR) test is performed.
The AABR test involves placing 3 electrodes on the infant’s forehead and neck.
Clicking sounds are then played. The electrodes would measure brain wave activity in
response to the clicks.
Given that AOAE test is not even an option in this question, the next most appropriate
answer would be the AABR test. AABR also has the benefit of detecting auditory
neuropathy in children who are deaf but have normal otoacoustic emissions (i.e. in
those who have a normal cochlea).
Q-60
A 62 year old man with a long history of smoking and alcohol presents with nasal
obstruction, and on and off nose bleeds. He has a noticeable lump on his upper
neck. He is having difficulty hearing with his left ear and has had worsening ear
pain in that ear. Examination reveals conductive hearing loss in the left ear.
A. Nasopharyngeal carcinoma
B. Paranasal sinus carcinoma
C. Oesophageal carcinoma
D. Oropharyngeal carcinomas
E. Hypopharyngeal carcinoma
ANSWER:
Nasopharyngeal carcinoma
EXPLANATION:
The first symptom of nasopharyngeal carcinoma is often a painless swelling or lump in
the upper neck. This is often due to a swollen lymph node. Other symptoms include
nasal obstruction, epistaxis and otitis media from eustachian tube obstruction. Hearing
loss (conductive deafness) in one ear and tinnitus are also symptoms seen in
nasopharyngeal carcinoma.
Smoking and alcohol can increase the risk of nasopharyngeal carcinoma but then
again, they increase risk in many other types of cancers. One specific risk factor for
nasopharyngeal carcinoma is an infection with the Epstein-Barr virus.
Q-61
A 33 year old patient has a 2 year history of progressive sensorineural hearing
loss and loss of corneal reflex on the left side. He is noted to have reduced facial
sensation on that same side. He also complains of tinnitus and vertigo. What is
the SINGLE most definitive investigation?
A. Computed tomography of internal auditory meatus

B. Nuclear imaging of brain
C. Magnetic resonance imagingof internal auditory meatus
D. Radioisotope scan
E. X-ray skull
ANSWER:
Magentic resonance imaging of internal auditory meatus
EXPLANATION:
Hearing loss, tinnitus, vertigo points towards an affected vestibulocochlear nerve.
Absent corneal reflex and reduced facial sensation are due to the trigeminal nerve being
affected.
Acoustic neuroma could account for these set of symptoms in which case MRI of the
internal auditory meatus would reveal a benign tumour at the cerebellopontine angles
causing their effects by exerting pressure on the surrounding structures.
MRI of the internal auditory meatus is a dedicated scan to look at the cerebellopontine
angles. If required, an MRI of the brain could be requested later for further evaluation of
the mass.
Q-62
A 17 year old man presents with sore throat for several days and dysphagia.
Examination reveals a unilateral bulge, above and lateral to his left tonsil. The
bulge was noted to be red and inflamed. The examination of the oral cavity was
proven to be difficult as he had mild trismus. Drooling of the salive was seen.
What is the SINGLE most appropriate management?
A. Lymph node biopsy
B. Intravenous antibiotics and analgesics
C. Intravenous antibiotics, incision and drainage
D. Excision biopsy of bulge
E. Tonsillectomy
ANSWER:
Intravenous antibiotics, incision and drainage
EXPLANATION:
The stem here gives a typical presentation of peritonsillar abscess. Difficulty in
swallowing can result in drooling.
The changes in microbiology of the causative orgainsm and their resistance is the
primary reason antibiotics alone is not sufficient as treatment. Incision and drainage of
aspiration in combination with intravenous antibiotics is the preferred option. Needle
aspiration, incision and drainage and quinsy tonsillectomy are all considered acceptable
surgical management for acute peritonsillar abscess.
Peritonsillar abscess (quinsy)

• A complication of acute tonsillitis
• Pus is trapped between the tonsillar capsule and the lateral pharyngeal wall
• Typically preceded by a sore throat for several days
Presentation
• Sore throat
• Dysphagia
• Pain localized to one side of the throat
• Peritonsillar bulge
• Uvular deviation → Bulging tonsil pushes the uvula away from the affected side
• Fever
• Trismus (difficulty opening the mouth)
• Altered voice quality ('hot potato voice') due to pharyngeal oedema and trismus
Management
• Antibiotics (usually IV benzylpenicillin) and aspiration or formal drainage
Q-63
A 6 year old child fell on his nose 3 days ago. His parents have now brought him
to the hospital as he is having difficulty in breathing and feeling unwell. He has
general malaise and complains of nasal pain. On examination, nasal bones are
seen to be straight however, there is tenderness over the dorsum of the nose. He
has a temperature of 38.9 C. What is the SINGLE most likely diagnosis?
A. Nasal polyp
B. Nasal septal haematoma
C. Nasalseptal abscess
D. Deviated nasal septum
E. Fractured nose
ANSWER:
Nasal septal abscess
EXPLANATION:
Nasal septal abscess is the likely diagnosis here given the temperature and general
malaise. Nasal septal abscess is where there is a collection of pus between the
mucoperichondrium and septal cartilage. It results from a bacterial infection of a nasal
septal haematoma. This is why it is particularly important to incise and drain a septal
haematoma as to prevent an abscess from forming.
Q-64
A 46 year old man has a long history of chronic sinusitis. He feels that his nose
is blocked and it does not clear and he occasionally sees blood when he blows
his nose. He now presents with pressure in his upper teeth, recent cheek
swelling, and double vision. On examination, left maxillary tenderness is noted
along with epiphora of the left eye. What is the SINGLE most likely diagnosis?
A. Nasopharyngeal carcinoma
B. Pharyngeal carcinoma
C. Paranasal sinus carcinoma
D. Laryngeal carcinoma
E. Hypopharyngeal tumour
ANSWER:
Paranasal sinus carcinoma
EXPLANATION:
Paranasal sinus tumours (maxillary, ethmoid, frontal, sphenoid) are commonly well-
differentiated squamous cell carcinoma. They present with signs and symptoms similar
to this stem which include with local swelling, pain, and ocular symptoms if the orbit is
involved. Pain particularly in the upper cheek, nasal obstruction, blood in nasal
discharge point towards a likely diagnosis of paranasal sinus carcinoma.
Q-65
A 72 year old man presents to the outpatient clinic with the complaint of a sore
throat. He says that he has had a sore throat for over three weeks now and that
the over the counter medication that he’s gotten from his local pharmacy is not
helping. Upon further questioning, the patient reveals that he has difficulty and
pain upon swallowing and his wife has noticed that his voice has gotten more
hoarse over the course of the past three weeks. He says that when he tries to
swallow, it feels like there’s a persistent lump in his throat. He has no neck pain,
no ear pain and no history of weight loss. There is a 2 x 3 cm palpable lump on
the anterolateral portion of his neck. What is the SINGLE most likely diagnosis in
this patient?
A. Tonsillitis
B. Peritonsillar abscess
C. Tonsil carcinoma
D. Mumps
E. Plummer-Vinson syndrome
ANSWER:
Tonsil carcinoma
EXPLANATION:
Although he has not complained of any weight loss, this patient has many signs and
symptoms of tonsil carcinoma.
Tonsillitis is incorrect. Although this patient complains of a sore throat, he has no pain,
no acute onset of symptoms, no fever and no swollen regional lymph nodes.
Peritonsillar abscess is incorrect. It usually starts with acute follicular tonsillitis,

progresses to peritonsillitis and results in formation of a peritonsillar abscess. Tonsillitis
is primarily a disease of young children however, it can affect adults as well.
Carcinoma of the tonsil is a type of squamous cell carcinoma. Risk factors include
smoking, regular alcohol intake and HPV infection. The most important sign is a
palpable lump in the neck, which this patient does not have.
Plummer-Vinson syndrome is a risk factor for oropharyngeal cancer, but it is not the
diagnosis in this patient.
Q-66
A 39 year old man has a history of swelling in the region of the submandibular
region, which became more prominent and painful on chewing. He also gives a
history of sour taste in the mouth and havinga dry mouth. On palpation, the area
is tender. What is the SINGLE most likely underlying diagnosis?
A. Chronic sialadenitis
B. Adenolymphoma
C. Mikulicz’s disease
D. Adenoid cystic carcinoma
E. Submandibular abscess
ANSWER:
Chronic sialadenitis
EXPLANATION:
Sialadenitis refers to inflammation of a salivary gland and may be acute or chronic,
infective or autoimmune.
The patients suffering from sialadenitis generally experience redness, swelling and pain
in the affected side of the mouth. This occurs due to the enlargement of gland as a
result of inflammation caused by bacteria or virus infection. The swelling may become
enormously enlarged, sometimes even reaching the size of an orange, with overlying
inflamed reddened skin and edema. Mild pain and swelling are usually common before
and during meals. Fluctuation test may be positive in the swelling if it is filled with fluid.
Other symptoms of sialadenitis include a foul taste in the mouth, decreased mobility in
the jaw, dry mouth, skin changes, weight loss, shortness of breath, keratitis, dental pain,
skin discharge and lymphadenopathy. The patient may run fever with rigors and chills
along with malaise and generalized weakness as a result of septicemia. In severe
cases, pus can often be secreted from the duct by compressing the affected gland. The
duct orifice is reddened with reduced flow. There may or may not be a visible or
palpable stone.
Q-67
A 2 year old child is brought by his mother. The mother had hearing impairment
in her early childhood and is now concerned about the child having a similar
condition. What is the SINGLE best investigation to be done for the child?
A. Conditioned response audiometry

B. Distraction testing
C. Scratch test
D. Tuning fork
E. Otoacoustic emissions
ANSWER:
Conditioned response audiometry
EXPLANATION:
Hearing tests in the children:
• < 6 months
o Otoacoustic emissions (OAE):
▪ Vibration of the hair cells in response to noise generates acoustic energy
which is detected by a microphone in the external meatus.
o Audiological brainstem responses (ABR):
▪ The ears are covered with earphones that emit a series of soft clicks.
Electrodes on the infant’s forehead and neck measure brain wave activity
in response to the clicks.
• 6-18 months:
o Distraction testing:
▪ As the child sits on parent’s lap, an assistant in front attracts the child’s
attention while a tester attempts to distract by making noises behind and
beside child, eg with a rattle, conversational voice.
• 2-4 years:
o Conditioned response audiometry:
▪ The child is trained to put pegs into holes or give toys to a parent on a
particular auditory cue.
o Speech discrimination:
▪ The child touches selected objects cued by acoustically similar phrases,
eg key/tree.
• 5 years:
o Pure tone audiogram
▪ Each ear is tested individually. The child presses a button when he hears
a tone.
Q-68
A 27 year old man had a fly enter his ear. He is anxious to get the fly removed.
What is the SINGLE best method for removal of the fly from his ear?
A. Removal with forceps

B. Removal under general anaesthesia
C. Instill mineral oil into his ear
D. Instill alcohol ear drops
E. Syringe his ear with normal saline
ANSWER:
Instill mineral oil into his ear.
EXPLANATION:
Points to remember for foreign bodies in the ear:
• Referral to an ear, nose and throat specialist is indicated in the following:
o If the patient requires sedation.
o If there is any difficulty in removing the foreign body.
o If the patient is uncooperative.
o If the tympanic membrane has been perforated.
o If an adhesive is in contact with the tympanic membrane.
• After removal the tympanic membrane must be checked - there may be a perforation
which must be treated.
• The following should be avoided:
o use of a rigid instrument to remove a foreign body from an uncooperative
patient's ear
o removal of a large insect without killing it first
o irrigating a seed from an ear canal. Water causes the seed to swell.
o removal of a large or hard object with forceps which may push them farther into
the canal
• Removal of the foreign body by syringing is not usually successful.
• Organic foreign bodies are more likely to cause infection.
• Spherical objects need to be hooked out. They cannot be grasped with forceps.
• Live insects cause great distress. Drown the insect in olive oil and if necessary then
syringe it out.
Q-69
A 55 year old woman presents with sudden onset of severe vertigo. She has a 4
week history of intermittent dizziness. These episodes typically occur when she
suddenly moves her head or roles in bed and are characterised by the sensation
that the room is ‘spinning’. Most attacks last a few seconds. Neurological
examination is unremarkable. She is a known hypertensive who has been on
ramipril for the last two years. What is the SINGLE most appropriate
management?
A. Perform Epley’s manoeuvre

B. Perform Hallpike’s manoeuvre
C. Stop antihypertensive medication
D. Antiviral medication
E. Prescribe amoxicillin
ANSWER:
Perform Epley’s manoeuvre
EXPLANATION:
Please see Q-32
Q-70
A 25 year old man presents with a history of pain and swelling in the
submandibular region that has been present for weeks. The pain is unilateral and
more prominent during eating. The area is tender on palpation. What is the
SINGLE most likely diagnosis?
A. Chronic sialadenitis
B. Adenolymphoma
C. Mikulicz’s disease
D. Adenoid cystic carcinoma
E. Salivary gland neoplasm
ANSWER:
EXPLANATION:
Pain, swelling, more pain on chewing, tenderness, suggests diagnosis of submandibular
chronic sialadenitis. Chronic sialadenitis is usually secondary to sialolithiasis (salivary
stone).
Sialadenitis
Refers to inflammation of a salivary gland and may be acute or chronic.
Acute sialadenitis
Acute sialadenitis is an acute inflammation of a salivary gland. Patients typically present
acutely in A and E with erythema over the area, pain, tenderness upon palpation, and
swelling. The infection is often the result of dehydration with overgrowth of the oral flora.
A common scenario would be postoperative dehydration. Purulent material may be
observed.
Chronic sialadenitis, in contrast, is typically less painful and is associated with recurrent
enlargement of the gland (often following meals) typically without erythema. The chronic
form of the disease is associated with conditions linked to decreased salivary flow,
rather than dehydration. These conditions include calculi (sialolithiasis).
Q-71
A 45 year old man presents with progressive hoarseness. He has swollen vocal
cords. He has a body mass index of 34 kg/m2 and he smokes 20 cigarettes a day.
He also drinks 2 pints of beer a day. He has been suffering from heartburn since
he was mid twenties. His diet involves eating large amounts of red meat.
Investigations reveal that he has laryngeal cancer. What is the SINGLE most
likely cause of his cancer?
A. Diet
B. High BMI
C. Alcohol abuse
D. Gastro-oesophageal reflux disease
E. Smoking
ANSWER:
Smoking
EXPLANATION:
Chronic hoarseness is the most common early symptom of laryngeal cancer. The
typical
patient would be an elderly male patient who smokes and presents with progressive
hoarseness, then stridor, difficulty or pain on swallowing. Later with haemoptysis and
ear pain if the pharynx is involved.
While it is true that alcohol is a risk factor for laryngeal cancer, smoking is the main
avoidable risk factor and is known to be the number one cause of laryngeal cancers in
the UK.
Risk factors
• Smoking is the main avoidable risk factor for laryngeal cancer, linked to an
estimated 79% of laryngeal cancer cases in the UK.
• Certain occupational exposures (asbestos, formaldehyde, nickel, isopropyl alcohol
and sulphuric acid mist) can also cause laryngeal cancer.
• Insufficient fruit and vegetables intake is linked to an estimated 45% of laryngeal
cancer cases in the UK.
• Human papillomavirus type 16 (HPV16) seropositivity is associated with an
increased risk of oral, pharyngeal and laryngeal cancer.
Q-72
A 69 year old man is brought to the clinic by his family as they are concerned that
he is not hearing well. The family report that the patient expresses a decreased
ability to understand speech. He finds hearing difficult, especially in noisy
environments. Examination of the eardrum is normal. A pure-tone audiogram
reveals a sensorineural hearing loss that is bilateral and worse at high
frequencies. What is the SINGLE most likely diagnosis?
A. Otosclerosis
B. Presbycusis
C. Viral labyrinthitis
D. Impacted cerumen
E. Chronic otitis media
ANSWER:
Presbyacusis
EXPLANATION:
This man is suffering from presbyacusis.
Patients with presbyacusis often lose the ability to hear high-frequency sounds. Speech
has two components: vowels which are low-frequencies and consonants which are
high-frequencies. When the high-frequency sounds are lost, consonants are lost, which
results in difficulty in understanding speech.
“Don’t shout, I’m not deaf!’ is a common phrase used by elderly patients suffering from
presbyacusis. Shouting words to them would only increase the low-frequency sounds
and not the high-frequency sounds.
The management includes using hearing aids that increase the high-frequency sound.
In the UK, the NHS uses bilateral digital hearing aids.
Otosclerosis is a distractor. It usually occurs at an earlier age. Otosclerosis is a

conductive hearing loss and more importantly, the affected individual would report better
hearing when in noisy environments which is an opposite finding from presbyacusis.
PRESBYACUSIS
Presbyacusis, also known as age-related sensorineural hearing loss is the most
common cause of hearing impairement in elderly patients. The aetiology is thought to
be degenerative changes in the inner ear.
Clinical features
• Progressive high-frequency hearing loss
• Bilateral
• Usually occurs after age 50
• Difficulty understanding speech, especially in noisy environments
• Usually brought in by the family to clinics as the patient woiuld not think his/her
hearing is impaired.

Questions&Answers: Meniere's Disease Presentation

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ENT

Note that vertigo and nausea can be alleviated by prochlorperazine,

A. Arrange hearing test

Symptoms of hearing loss include, but are not limited to:

When should we refer for a hearing assessment?

Removal by hook is not suitable if the child is uncooperative.

Referral to an ear, nose and throat specialist

Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Symptoms of temporomandibular disorders include facial pain, restricted jaw function

Diabetics or patients who are on immunosuppressive drugs are more predisposed to

A. Recurrent laryngeal nerve palsy

Laryngeal obstruction like angioedema would have difficulty in breathing.

A. Perforation of tympanic membrane

Otitis media with effusion

Note: In this question it is unlikely to be Infectious mononucleosis (glandular fever) as it

A. Olive oil ear drops

If symptoms persist, consider ear irrigation

If irrigation is unsuccessful, there are three options:

Sinus headaches are an uncommon type of headache caused by inflamed sinuses. It

COMPARING VESTIBULAR NEURITIS AND LABYRINTHITIS

A. Press the base of the nose

Note that vertigo and nausea can be alleviated by prochlorperazine, cinnarizine,

Other hints in this stem are:

• Female gender – otosclerosis usually occurs in females (2:1 female:male ratio)

Rinne's and Weber's test

Otosclerosis is the commonest cause of progressive deafness in young adults. It

Untreated, the deafness gradually worsens. Other symptoms of otosclerosis include

It is progressive and there is no curative treatment at the moment. The management

Key features for otosclerosis:

A. Bilateral sensorineural hearing loss

A. Acute otitis media

Acute otitis media in children

OTITIS MEDIA VS OTITIS EXTERNA

Otitis media Otitis externa

Features • May be seen with a bulging • Serous discharge

A. Acute Suppurative Otitis Media

Congenital cholesteatoma is incorrect. Perforation is seen less commonly with

It can be either congenital or acquired.

Remember: Cholesteatoma is suggested by the following:

A. Fine needle aspiration (FNA) cytology

BENIGN PAROXYSMAL POSITIONAL VERTIGO

COMPARING VESTIBULAR NEURITIS AND LABYRINTHITIS

Haemoglobin 122 g/L

What is the SINGLE most likely cause of the bleed?

A. Perforation of tympanic membrane

Note that nasal polyps tend to be bilateral.

It is particularly important to remember the association with asthma.

A. Otitis media with effusion

Occasionally, hearing loss and fever may be seen in the stem.

A. Acute otitis media

A. Olive oil ear drops

Referral to an ear, nose and throat specialist

A. Herpes zoster infection

A. Flamingo pink tympanic membrane

A. Right sensorineural deafness

A. Benign parotid tumour

A. Computed tomography of internal auditory meatus

Sometimes, in the stem, they would include facial palsy as a feature.

A. Right sensorineural deafness

A. Magnetic resonance imaging of the head

The hearing screening programme offers 2 types of test:

Automated otoacoustic emission (AOAE) test takes a few minutes. A soft-tipped

A. Computed tomography of internal auditory meatus